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cmi% jUAwUlw LUUAL HEALTH DISIRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITEXAME FACILITY CONTACT NAME <br /> A <br /> C - �� may <br /> L STREET ADDRESSSITE PHONE I WITH AREA COOK <br /> I :7S 'I C,\ <br /> T <br /> Y CITY STAT ZIP CODE f of Tanks <br /> �o� �Ot1 at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE t WITH AREA CODE <br /> C <br /> A <br /> N CITY STAT ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A- <br /> C 1986 1987 1988 1989 <br /> T <br /> I C) o Io0 loc_7 f <br /> V-- <br /> E TANK FEE _ $50.00 each TANK <br /> F $ Tanks 4 x $50.00 1986 1987 1988 1989 <br /> A (multiply- by fee for <br /> C each year applicable) L��� I �x'� Lw f <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH b SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks z $56.00 1986 1987 1988 1989 <br /> Y (enter iiount and ycar) <br /> Cef�c s <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK _Tanks x $90.00 $ <br /> S <br /> R TEMPORARY CLOSURE (Only alloyed one time for up to two years) <br /> E _ <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK t Tanks x $80.00 f <br /> fP PLAN CHECK (Installation or Repair) A P AY M E T <br /> [INCg`1� <br /> MAR <br /> N PLAN CHECK FEE = $30.00 each SUBMISSION/RESUBMISSION <br /> tAPIPING <br /> PAIR <br /> ------ WFAI T14 <br /> — <br /> NK REPAIR FEE _ $110.00 each TANK f Tanks x Si10.00PERMIT�SERV(LES <br /> - - <br /> -- _. <br /> REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal)UTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> en applicable) (when applicable) (when applicable) <br /> = $30.00/hr FEE = 135.001hr FEE = $35.00/hr f <br /> TOTAL DUE C� <br /> OFFICE USE ONLY �j�C/� j <br /> SWEEPS t COMP f LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK If ASH RCVD BY DATE RECEIVED PERMIT f <br /> C�' 3 VS. <br />